Schedule 3(b)
Therapeutic Use
Exemption (TUE)
Application Form /
NB Please note that APPLICATIONS FOR INHALED BETA-2 AGONISTS (ASTHMA INHALERS) WILL NOT BE ACCEPTED ON THIS FORM and instead must be submitted on the separate beta-2 agonist TUE form (see Schedule 3c of the SRU Anti-Doping Regulations).
TUE applications will not be reviewed unless additional medical evidence is submitted with this application to justify the need for Therapeutic Use Exemption. Medical evidence to confirm the diagnosis should include:
§ Comprehensive medical history and the results of all relevant examinations, laboratory investigations and imaging studies
§ Copies of original reports, letters, and specialist reviews
§ Clinical justification of the use of a Prohibited Substance or Prohibited Method when there are reasonable alternative medications available
Please complete all sections in BLOCK CAPITALS. Incomplete or illegible forms will be returned unprocessed.
1. Athlete Information (athlete to complete)
Surname: First names:
Date of Birth (dd/mm/yy): // Gender: Male Female (please tick)
Address:
Postcode –
Contact Tel. (including dialling code) 1.
2.
E-mail:
Sport: RUGBY UNION Club:
(indicate the discipline if appropriate)
National Governing Body: SRU Disability category:
Level of competition: (please tick one box as appropriate – if unsure, check with the SRU Anti-Doping Administrator))
I am in the IRB’s Registered Testing Pool
I am competing in an International event
I am in the SRU’s National Registered Testing Pool
I am competing in a National Level event in my sport
Other (please state level)
Next competition the Therapeutic Use Exemption is required for:
Competition date (dd/mm/yy): //
(a) Have you at any time previously submitted a TUE application? Yes No
(b) The Anti-Doping Organisation applied to? UK Anti-Doping IRB Other
(c) Decision: Approved Declined
NB: YOU THE ATHLETE MUST COMPLETE SECTION 4 AND ENSURE SECTIONS 2 AND 3 ARE COMPLETE, BEFORE SUBMITTING THIS APPLICATION.
2. Medical Information (Medical Practitioner to complete)
Diagnosis (please attach medical evidence to support this diagnosis):
Medical examination(s)/test(s) performed (please attach the results of medical investigations completed):
Prohibited Substance(s)(Generic Name) / Dose and units of administration / Route of administration / Frequency of administration
1.
2.
3.
4.
Intended duration of treatment(s): Once only Emergency Weeks/Months
Please specify duration:
If a permitted medication can be used to treat the medical condition, provide clinical justification for the requested use of the prohibited medication prescribed:
3. Notifying Medical Practitioner Details and Declaration
Contact Tel.
E-mail:
I certify the above-mentioned substance(s) for the above named athlete has been/are to be administered as the correct treatment for the above named medical condition. I further certify that the use of alternative medications not on the Prohibited List would be unsatisfactory for the treatment of the above named medical condition.
If the athlete is under 18 and I have not notified the athlete’s parent/guardian, this is because I consider the athlete to be competent to give consent to treatment.
I understand that my details will be held on an anti-doping database and will be accessible by the Athlete, their National Governing Body, their International Federation, UK Anti-Doping, and the World Anti-Doping Agency in order to allow them to administer the anti-doping programme.
Signature of medical practitioner: ______Date: //
If the athlete is under 18 does the athlete’s parent/guardian know about this treatment? Yes No
Are the relevant medical reports and examination/test results attached to this application? Yes No
4. Athlete’s Declaration (athlete to complete)
I certify that the information under Section 1 of this TUE application form is accurate and that I am requesting approval to use a substance or method on the World Anti-Doping Code (WADC) Prohibited List.
I authorise the release of personal medical information related to this application as appropriate to the SRU, the IRB, the National Anti-Doping Organisation in the UK (UK NADO, currently UK Anti-Doping) as well as to World Anti-Doping Agency (WADA) staff, to the appropriate NADO or IRB Therapeutic Use Exemption Committee (TUEC) and to other Anti-Doping Organisations (ADO) under the provisions of the WADC and the anti-doping rules of my Sport.
I understand and agree that:
· My TUE data will only be used to allow the above organisations to administer the anti-doping programme in accordance with the WADC International Standard for TUEs;
· My TUE data will be sent by the SRU to the UK NADO or IRB, one of whom shall be principally responsible for ensuring the protection of this data. The UK NADO or IRB will use the Anti-Doping Administration and Management System (ADAMS) to store, process and manage my data, including its disclosure to authorised recipients;
· My TUE data, or part of it, will be made accessible to authorised ADOs (for instance, other designated NADOs, Tournament Organisers in my Sport, and WADA);
· My TUE data may have to be shared with other independent medical and/or scientific experts, and all necessary staff involved in the management, review or appeals of TUEs if applicable;
· Persons or parties receiving my information may be located outside the country where I reside. In some other countries data protection and privacy laws may not be equivalent to those in my own country;
· I may have certain rights under applicable laws in relation to my TUE data, including rights to access and/or correct any inaccurate data; and
· To the extent that I have any concerns about the processing of my TUE data I may consult with the SRU, UK NADO and/or IRB and/or WADA as appropriate.
Withdrawal of Consent
I understand that if I ever wish to revoke the right of the SRU, UK NADO, IRB & authorised ADOs (designated NADOs, Tournament Organisers in my Sport, and WADA) to access my TUE information, I must notify my medical practitioner and the SRU in writing of that fact.
Authorisation and Consent
By signing this form I expressly consent to the use of my TUE data as set out above.
In addition to the decision being sent to the SRU by e-mail to , I would like the decision to be sent to: (please tick one box as appropriate)
My postal address My e-mail address The notifying medical practitioner
Athlete’s signature: ______Date: //
Parent/guardian signature ______Date: //
(If the athlete is under 18 and is not deemed to be competent to give their consent to the treatment or has a disability preventing him/her to sign this form, a parent or guardian shall sign together with or on behalf of the athlete).
keep a copy for your records and submit the form to THE SRU at:
tue (Confidential), Anti-Doping, Scottish Rugby, Murrayfield Stadium, Edinburgh, EH12 5PJ
Confidential Fax: 0131 346 5077 (NB not the main SRU fax) / e-mail:
(NB In case of emergency medical treatment when SRU offices are closed, please fax or email your signed TUE application to:
TUE, UK Anti-Doping
Confidential fax: 0800 298 3362 / e-mail: )
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SRU Version 2013